VBS Registration Form
July 17-20, 2023
We are looking forward to your student attending Together at Warren VBS. Please fill out the following information completely.
My student will attend:
*
Entering PK - 5th Grade (9:00 AM - 12:00 PM)
Middle/High School/Adult VBS (3:30-6:30 PM)
Basic Student Information
Name
First Name
Last Name
Gender:
Female
Male
Date of Birth
-
Month
-
Day
Year
Date
What is your student's t-shirt size?
Adult XS
Adult S
Adult M
Adult L
Adult XL
Adult XXL
Youth S
Youth M
Youth L
Youth XL
Parent/Caregiver Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Cell Phone Number
Please enter a valid phone number.
May we contact you through text message?
Yes
No
Do you attend church locally?
Yes
No
If yes, where do you attend?
Student Specific Information
Is your student a current Together at Warren participant?
Yes
No
Is your student verbal or non-verbal?
Non-verbal
Verbal
What is the best way to communicate with your student? (One step directions, sign language, picture cards, etc.)
What is the chronological age of your student?
What is the developmental age of your student?
What are some things your child loves to do or has a special interest in?
Is your student physically harmful to himself/herself or others?
Yes
No
If yes, please explain.
Please list any medical needs or allergies that we should be made aware of.
Please check which of the following snacks that your student may have:
animal crackers
goldfish
Oreos
chocolate chip cookies
pretzels
More About Your Student
Please share your student's diagnosis or disability.
Does your student elope (escape/run away)?
Yes
No
What are your main concerns for your child at this event?
Does your student need assistance in the restroom? If so, explain.
Additional Information
Is there any other information you would like for our team to know?
I consent to allowing my child to be photographed and understand these images may be shared on the Warren website and/or social media:
*
Yes
No
Medical Consent
Name
Diagnosis/Disability
Hospital Preference
Current Medication
In case minor first aid is needed: (Example: a cut needs a bandaid)
Administer first aid and then call
Call before administering any type of first aid
LIABILITY RELEASEPLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND CHECK THAT YOU HAVE READ, UNDERSTAND, AND AGREE TO THE PROVISIONS.
I have fully disclosed to Warren Baptist Church all pertinent facts about my child’s special needs (Cognitive, Physical, Mental, Medical) and accept full responsibility for missing information. I agree for this information to be disclosed to the approved volunteers at Warren as appropriate, so they may best care for my child. I acknowledge and accept the risks of injury associated with my child’s pre-existing condition while participating in Ministry activities. I acknowledge and accept the risks of injury or harm associated with intervention and/or treatment performed by Ministry workers. I agree on behalf of both the guardian and the child, to indemnify, defend, and hold harmless the ministry, and its agents, employees, volunteers, and other representatives for any injury or incident arising directly or indirectly out of the described medical needs of my child.
I have read, understand, and agree to the provisions listed above.
Yes
No
Does your student have a history of seizures?
Yes
No
If your student has a history of seizures, please fill out the following Seizure Action Plan:
Seizure Action Plan: Contact Parent/Caregiver if:
Seizure Action Plan: Call 911 if:
Consent: By selecting yes in the following area, you are acknowledging that all information regarding the Seizure Action Plan is true to the best of your knowledge. Also, by filling out the information in the Seizure Action Plan, you are giving permission to the representatives of Warren Baptist Together at Warren Special Needs Ministry to act as you have indicated on behalf of your student.
Yes
No
Parent/Caregiver Name
Relationship to student
Phone Number
Please enter a valid phone number.
Emergency Contacts (other than person whose information has already been provided)
Name
Phone Number
Please enter a valid phone number.
Name
Phone Number
Please enter a valid phone number.
Submit
Should be Empty: